1) The document discusses various tests and examinations used to evaluate macular function and identify potential macular pathologies, including inspection, refraction, pinhole testing, Ishihara color plates, Amsler grid, fundus photography, and optical coherence tomography. 2) Common macular conditions that can be identified include age-related macular degeneration, diabetic maculopathy, central serous retinopathy, macular hole, and hereditary macular degenerations. 3) Special tests discussed are microperimetry, fluorescein angiography, photostress testing, and optical coherence tomography which provide additional information about the macula.

1. Macular Function Test and Clinical assessment Dr. AnandSudhalkar Baroda 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 1

2. Why look at Macula? Clinically compelling situations Pointing Symptoms Vision does not improve after cataract surgery After refraction Referred cases with unexplained vision loss Children with strabismus Inability to read fine prints Metamorphopsia Minification, magnification Obstruction: Positive/Negative scotomas Colour vision changes 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 2

3. What are we looking for? Known Macular Pathologies “Other” conditions CME, CSR Macular Hole Heredomacular degenerations Retinoblastoma Infective conditions Trauma, Eclipse burns ARMD Diabetic Maculopathy Retinal Vascular Diseases Vitreoretinal conditions Amblyopia Astigmatism Nystagmus Masquerades Neurological: Pituitary Hemianopia, Optic neuritis Toxic amblyopias Inferior RD Advanced glaucomatous damage Malingering 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 3

4. Multiple sclerosis UHTHOFF'S SIGN OR PHENOMENON: This is a temporary worsening of vision and other neurologic functions commonly seen in patients with multiple sclerosis just after exertion or in situations where they are exposed to heat. The condition is of importance because multiple sclerosis (a demyelinizing condition which can be related to optic neuropathy) may present with optic neuritis. Patients may report they notice their central vision becomes blurry and will show a positive defect when tested with an amsler grid. The condition is commonly reported after exercising or simply sitting in front of a fireplace, it is important if you suspect multiple sclerosis that you ask questions related to this phenomenon. PULFRICH PHENOMENON: There have been reported cases of patients with multiple sclerosis who experience this phenomenon. Using the test diagnostically is somewhat questionable, however, suspect patients should be questioned. It is the perception (a binocular stereo phenomenon) that objects they know are moving in a straight line appear to be moving in an elliptical pattern. These patients may suddenly start having motion sickness problems unrelated to an ear infection. They may also complain that things just look odd to them or they are having problems with depth perception. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 4

5. Routine Examination: How to look? Inspection Common tests Eccentric viewing, Searching movements Pupillary reflex: Fixation Reflex Refraction Pinhole Ishihara Charts Macular Field of vision by: Amsler/ Auto perimeter 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 5

6. How best to see?Binocular Indirect 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 6 Panoramic view, 4* mag. , 14 and 20D

7. Slit Lamp Biomicroscopy 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 7

8. Documentation, Comparison, progress/prognosis, Treatment monitoring patient education Fundus Camera FFA CSR 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 8

9. Macular (Foveal) acuity charts Vryghem Macular Function Test: The Parinaud chart ETDRS Chart 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 9

10. Amsler Grid: Each square measures 5 mm and when the grids are held at 30 cm from the patient each square subtends 1 degree on the retina. The First Grid Has White Lines On A Black Back Ground And Central White Dot On Which The Patient Is To Fixate. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 10

11. If The Patient Reports On The First Chart They Cannot See The Central White Spot. This Would Indicate A Positive Scotoma. The Following Chart Should Be Used On Which Diagonal Lines Help Maintain Central Fixation. This Helps Them Point Out The Limits Of The Scotoma. This Chart Also Has White Lines On A Black Back Ground And Central White Fixation Dot. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 11

12. The Third Chart Has Red Lines On A Black Back Ground And Is Very Helpful In Diagnosis Of Optic Nerve, Chiasmal, Or Toxic Amblyopia Related Problems. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 12

13. Central Scotoma As Seen By A Patient With A Positive Or Absolute Scotoma. For Example This Might Be Secondary To Central AreolarChoroidal Dystrophy Or Congenital Toxoplasmosis . 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 13

14. Next is An ArcuateScotoma As Seen By An Advanced Glaucoma Patient. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 14

15. Above A Positive Or Absolute ParacentralScotoma As Seen By The Patient That Might Be The Result Of A Healed Chorioretinal Scar. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 15

16. A Space-Taking Pathology Such as A Tumor That Forces The Cones Closer Together Will Cause The Grid To Be Seen Distorted. The Retinal Image Will Fall On More Cones Than Normal And The Lines Of The Amsler Grid Will Be Seen As Larger And Bend Outward As In The Above. This Is Known As "Macropsia". 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 16

17. A Patient With Macular Edema Or Any Other Pathology That Forces The Cones Apart The Retinal Image Will Stimulate Fewer Cones Than Normal And The Lines Of The Amsler Grid Will Be Seen As Smaller And Tend To Bend Away From The Patient. This Condition Is Termed "Micropsia". 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 17

18. A Combination Of Squeezing And Spreading Of The Cones Causes An Overall Distortion Of The Image. The Lines Of The Amsler Grid Become Distorted And Non-Uniform. This Can Occur In A Number Of Macular And Retinal Conditions. This Condition Is Termed Metamorphopsia. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 18

19. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 19 Macular Field of Vision

20. 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 20 Thank You

21. Special tests Macular Field of vision Bailliart (1954) photostress test FFA OCT SLO microperimetry, Preferential hyperacuity perimeter 1/2/2010 Sudhalkar Eye Hospital and Retinal Laser Centre 21